SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA COURT APPOINTMENT FORENSIC EVALUATION COMPENSATION CLAIM FORM AND SUPPORTING AFFIDAVIT Doctor's Name: Defendant/Minor Full Name: Type of Proceeding: Date of Appointment: Case Number: Adult W&I 6605 Juvenile Competency Report Other: Adult PC1368/1369 Adult PC1026/1027 Adult EC1017* Adult PC 288.1 Juvenile WIC 702.3 (d) Juvenile EC1017* *EC 1017 Report: Date report submitted to Defense Counsel: Evaluation Interview Date of Interview: Preparation for Interview: Duration of Interview: Pages Reviewed: Testing No Testing Amount of Testing: Types of Test(s) Administered: 1 hour 2 hours Fee Calculation Basic Evaluation and Report Fee (first two hours) $350: Testing (two hours maximum) @ $95/hr MD or $85/hr PhD: Pre-approved additional funding (Attach approved request form CR-6080) (If Request for additional funds not attached it will delay payment) Testimony time in Dept. # Testimony date(s): Other: Total Compensation Requested: @ $250/ half-day and/or $425/ full day $ $ $ $ $ $ I hereby declare under penalty of perjury that to the best of my knowledge the foregoing information is true and accurate in every respect. Date Evaluator's Signature Mailing Address: Phone#: FOR COURT USE ONLY I acknowledge receipt of the report or appointment under EC 1017 and the services are rendered as requested. Approved by: Asst. Director/Juvenile Supervisor CR-6079 REV 8/5/14 Court Appointment Forensic Evaluation Compensation Claim Form and Supporting Affidavit American LegalNet, Inc. www.FormsWorkFlow.com Dated: